Eleighwater House

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

People received safe care which met their needs and respected their rights.

This service scored 75 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

We did not look at Learning culture during this assessment. The score for this quality statement is based on the previous rating for Safe.

We did not look at Safe systems, pathways and transitions during this assessment. The score for this quality statement is based on the previous rating for Safe.

People felt safe at the home and with the staff who supported them. During the site visit we saw kind and respectful interactions between people and staff. People told us; "Yes I feel safe, I couldn’t have a better home" and “If I was unhappy I would speak to staff if there was a problem, if you have a problem they are kind and sort it. Yes I feel safe.”

The Mental Capacity Act 2005 (MCA) provides a legal framework for making particular decisions on behalf of people who may lack the mental capacity to do so for themselves. The MCA requires that, as far as possible, people make their own decisions and are helped to do so when needed. When they lack mental capacity to take particular decisions, any made on their behalf must be in their best interests and as least restrictive as possible. People can only be deprived of their liberty to receive care and treatment when this is in their best interests and legally authorised under the MCA. When people receive care and treatment in their own homes an application must be made to the Court of Protection for them to authorise people to be deprived of their liberty. The service was working within the principles of the MCA. We saw staff supported people to make as many of their own decisions as possible. People had monitoring systems on doors and people had consented to these when they moved into the home. Following the site visit the registered manager advised best interest decisions regarding these restrictions were now in place where capacity had changed regarding this decision. Relatives were consulted when best interest decisions were needed. One relative told us they were involved in a best interest meeting regarding a medical procedure their loved one required. Where required, DoLS had been applied for in line with legislation and local practice.

People were kept safe from avoidable harm because staff knew them well and understood how to protect them from abuse. A policy was made available to staff and staff were able to tell us the appropriate action to take should they have any concerns.

There was a process in place to assess, manage and mitigate risk. We reviewed 4 people’s care records. Risks were assessed and areas covered included: Covid 19, falls, tissue viability, personal emergency evacuation plan, moving and handling, bed rails. Some of the risk assessments required additional information to record the measures that were in place to reduce the risk. Measures were put in place to minimise identified risks. For example, where people had specific health needs. The staff were proactive at ensuring risks to people were managed effectively in line with their wishes and abilities.

We spoke with 2 staff who knew people extremely well. They were aware of people's risk assessments and told us these provided all the information they needed to support them safely. We spoke with the registered manager who also knew people extremely well. They told us how people were enabled to take positive risks. For example, for 1 person who had their dog within the home with them, they were encouraged to take the dog out into the garden. The registered manager told us people were encouraged to do what they can and given an opportunity to access the community.

We observed people being supported safely. For example, we saw 1 person who required a modified diet being supported by staff in accordance with their risk management plan.

People and/or their relatives felt they were involved in assessing and managing risks. One relative told us their loved one was involved and encouraged and it was explained to them if something was not possible.

We did not look at Safe environments during this assessment. The score for this quality statement is based on the previous rating for Safe.

People told us staff were always available when they needed help or support. People said if they rung their call bells staff responded promptly. They told us, “Have a call bell we all have one, they are very efficient and come quickly”, and “Yes, if I call that [call bell] someone comes, never have to wait long.”

There was a recruitment system in place, however staff records lacked some relevant documentation in line with safe recruitment regulations. The registered manager confirmed during the assessment this had been rectified. Staff had not always received the training required. One person was being supported with a clinical task that had been delegated by a health professional. Best practice guidance was not always being followed in relation to this task and staff had not received training and competency assessments from a health professional. The risk was reduced as the person was able to complete this task themselves and guide staff. Following the site visit, the registered manager advised this person was now administering the insulin themselves until staff training and competency assessments had been completed by the district nurse. The registered manager had an oversight of staff training; however further development was required to ensure there was a system in place which provided a clear overview of staff's mandatory training, and any additional training staff had completed to clearly evidence staff capability to undertake certain tasks such as support people with delegated nursing tasks.

Staff told us they were happy in their roles and felt well supported. They told us they received appropriate training and supervision. The registered manager told us the home had a small team of staff which included a deputy manager and that they currently were not using any agency staff. They also explained the on call aranagements in place for out of hours.

Throughout the day we observed there were sufficient staff to meet people's needs and to keep them safe.

We did not look at Infection prevention and control during this assessment. The score for this quality statement is based on the previous rating for Safe.

We did not look at Medicines optimisation during this assessment. The score for this quality statement is based on the previous rating for Safe.